Alcohol Screening


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Development of the 5+ Drinks Screening Measure and the General Screening Procedure

The aims of the community study were and continue to be the investigation of the natural history of heavy drinking, alcohol abuse and dependence, and the reliability and validity of conceptualizations of alcohol use disorders. At the beginning of the study, an efficient and cost-effective method was sought to create a sample from the general population that would include some subjects meeting criteria for alcohol abuse and dependence, some subjects with dependence and/or abuse symptoms but no diagnosis, and some subjects with no alcohol diagnoses who could serve as a control or comparison group. A decision was made to conduct very brief screening of individuals from a defined geographic area so that abstainers and light drinkers (whose drinking would not have been informative for the research questions of the study) could be excluded.

For this purpose, a screening criterion was needed. A screening criterion with an overly low threshold would not have been efficient, since it would not have yielded a sufficiently high proportion of subjects with alcohol abuse or dependence. An overly stringent screening criterion would have required us to screen many more individuals (possibly several hundred more) before arriving at the necessary sample size, with the additional disadvantage of losing some individuals who met criteria for very mild alcohol abuse or dependence. To develop a screening criterion that would avoid both these possibilities, we conducted analyses to identify a brief, efficient screening question on drinking that would produce a sample with the needed specifications.

At the time (1989), the best data set available for this purpose came from the 1984 national alcohol survey designed by the Alcohol Research Group (Hilton, 1987), an NIAAA-funded research center. Subjects in the 1984 survey were household residents aged 18 and above. This survey was the seventh in a series of national surveys on drinking practices and problems (Hilton and Clark, 1991). The sample, consisting of 5,221 subjects, was a multistage probability sample of the 48 coterminous states, with oversampling for African-Americans and Hispanics. Trained survey interviewers administered the fully-structured interview, which lasted about an hour. The interview included detailed questions on alcohol consumption, alcohol problems in a variety of areas, environmental influences on drinking behavior, and personality, attitude and acculturation scales.

The 1984 survey was not designed as a study of DSM-diagnosed alcohol use disorders. However, the questions on alcohol problems were detailed enough to construct measures of DSM-III-R alcohol dependence and abuse (Grant and Harford, 1990) by matching DSM-III-R criteria with symptom or problem items in the interview. Through this process, eight out of the nine dependence criteria were operationalized, in most cases with several items. Abuse was operationalized fully. A number of papers were published on DSM-III-R alcohol use disorders from these data (Hasin and Glick 1992; 1993; Hasin 1994; Grant and Harford, 1988). The method allowed examination of DSM-III-R alcohol dependence and abuse in national data prior to the larger national surveys that followed, the 1988 NHIS (Grant, 1992), the NCS (Kessler et al., 1994) and the NLAES (Grant, 1997). In analyses conducted to identify the screening criterion, symptoms were considered positive if they occurred within the year prior to the interview.

The alcohol consumption section of the interview for the 1984 ARG survey included the following question, "During the last year, what is the largest number of drinks you had at any one time?" We used data from this question to determine the proportion of subjects reporting different numbers of drinks who evidenced current DSM-III-R dependence or abuse. We conducted these analyses for the full sample, as well as for males and females separately.

Of the males in the sample, 49.9% reported having five or more drinks in response to this question, while 23.4% of the females reported having five or more drinks. Of those who had five or more drinks, 19% of the males and 14% of the females met criteria for DSM-III-R alcohol dependence. Further, 9% of the males and 8% of the females who reported having five or more drinks at least once in the previous year met criteria for DSM-III-R abuse.

Of those who reported having five or more drinks on a single occasion who did not meet criteria for current DSM-III-R dependence or abuse, about 20% reported at least one symptom of abuse or dependence. Thus, about half of those who drank five or more drinks at least once reported at least one dependence or abuse symptom.

Of those who did not drink as many as five drinks at least once (i.e., their highest number was four or less), less than 1% met criteria for abuse or dependence. Thus, an extremely small number of subjects with an alcohol use disorder appeared to be missed with this drinking criterion as a screen. Note that others have since analyzed the 5+ drinks threshold as an indicator of risk for alcohol use disorders in more recent samples (Dawson and Archer, 1993; Caetano et al, 1997). Their results were very similar to ours, thus generally supporting our previously unpublished results. Others also found this to be a meaningful threshold of drinking, increasing risk for partner violence (Field and Caetano, 2003), emergency room use for an alcohol-related injury (Cherpitel et al., 2003), and overall intensity of alcohol-related physical, social, and occupational problems (Bourgault and Demers, 1997).

The screening criterion was implemented into the study by imbedding it in a very brief set of questions on health behaviors, including exercise, eating, and smoking. We did this to provide a natural context for the screening question that would not affect response among those who might be inclined to refuse participation in a study entirely focused on alcohol.


Bourgault C, Demers A. Solitary drinking: a risk factor for alcohol-related problems? Addiction 92: 303-12, 1997.

Caetano R, Tam T, Greenfield TK, Cherpitel C, Midanik LT: DSM-IV alcohol dependence and drinking in the U.S. population: a risk analysis. Annals of Epidemiology 7:542-549, 1997.

Cherpitel CJ, Bond J, Ye Y, Borges G, MacDonald S, Stockwell T, Giesbrecht N, Cremonte M: Alcohol-related injury in the ER: a cross-national meta-analysis from the Emergency Room Collaborative Alcohol Analysis Project (ERCAAP). Journal of Studies on Alcohol 64: 641-9, 2003.

Dawson DA, Archer LD: Relative frequency of heavy drinking and the risk of alcohol dependence. Addiction 88:1509-18, 1993.

Field CA, Caetano R: Longitudinal model predicting partner violence among white, black, and Hispanic couples in the United States. Alcohol Clinical andExperimental Research 27: 1451-8, 2003.

Grant BF, Harford TC: The relationship between ethanol intake and DSM-III alcohol use disorders: a cross-perspective analysis. Journal of Substance Abuse 1:231-52, 1988.

Grant BF, Hartford TC: The relationship between ethanol intake and DSM-III-R alcohol dependence. Journal of Studies on Alcohol 51:448-456, 1990.

Grant BF: Prevalence of the proposed DSM-IV alcohol use disorders: United States, 1988. British Journal of Addiction 87:309-16, 1992.

Grant, BF: Prevalence and correlates of alcohol use and dependence in the United States: results of the National Longitudinal Alcohol Epidemiologic Survey. Journal of Studies on Alcohol 5:464-473, 1997.

Hasin D, Glick H: Severity of alcohol dependence: results from a national survey. British Journal of Addiction 87:1725-1730, 1992.

Hasin D, Glick H: Depressive symptoms and DSM-III-R alcohol dependence: general population results. Addiction 88:1431-1436, 1993.

Hasin D: Treatment/self-help for alcohol-related problems: relationship to social pressure and alcohol dependence. Journal of Studies on Alcohol 55:660-666, 1994.

Hilton ME: Drinking patterns and drinking problems in 1984: Results from a general population survey. Alcohol Clinical and Experimental Research 11:167-175, 1987.

Hilton ME, Clark WB: Changes in American drinking patterns and problems, 1967-1984. In Pittman DJ, White HR (Eds). Society, Culture, and Drinking Patterns Reexamined. Alcohol, culture, and social control monograph series. (pp. 157-172). Piscataway, NJ: Rutgers Center of Alcohol Studies; Rutgers Center of Alcohol Studies, 1991.

Kessler RC, McGonagle KA, Zhao S, Nelson CB, Hughes M, Eshleman S, Wittchen H, Kendler KS: Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the US: results from the National Comorbidity Survey. Archives of General Psychiatry 51:8-19, 1994.


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